MEDICINE
Original Article
The Conservative Treatment of Traumatic
Thoracolumbar Vertebral Fractures
A Systematic Review
Ulrich J. Spiegl, Klaus Fischer, Jörg Schmidt, Jörg Schnoor, Stefan Delank,
Christoph Josten, Tobias Schulte, Christoph-Eckhardt Heyde
Summary
Background: The conservative treatment of traumatic thoracolumbar vertebral
fractures is often not clearly defined.
Methods: This review is based on articles retrieved by a systematic search in the
PubMed and Web of Science databases for publications up to February 2018
dealing with the conservative treatment of traumatic thoracolumbar vertebral
fractures. The search initially yielded 3345 hits, of which 35 were suitable for use in
this review.
Results: It can be concluded from the available original clinical research on the
subject, including three randomized controlled trials (RCTs), that the primary
diagnostic evaluation should be with plain x-rays, in the standing position if possible.
If a fracture is suspected on the plain films, computed tomography (CT) is indicated.
Magnetic resonance imaging (MRI) is additionally advisable if there is a burst
fracture. The spinal deformity resulting from the fracture should be quantified in
terms of the Cobb angle. The choice of a conservative or operative treatment
strategy is based on the primary stability of the fracture, the degree of deformity, the
presence or absence of disc injury, and the patient’s clinical state. Our analysis of
the three RCTs implies that early functional therapy without a corset should be
performed, although treatment in a corset may be appropriate to control pain.
Follow-up x-rays should be obtained after mobilization and at one week, three
weeks, six weeks, and twelve weeks.
Conclusion: Further comparative studies of the indications for surgery and specific
conservative treatment modalities would be desirable.
Cite this as:
Spiegl UJ, Fischer K, Schmidt J, Schnoor J, Delank S, Josten C,
Schulte T, Heyde CE: The conservative treatment of traumatic thoracolumbar
vertebral fractures—a systematic review. Dtsch Arztebl Int 2018; 115: 697–704.
DOI: 10.3238/arztebl.2018.0697
Department of Orthopedics, Trauma Surgery and Plastic Surgery, University Hospital of Leipzig,
Leibzig, Germany: PD Dr. med. Ulrich Spiegl, Prof. Dr. med Christoph Josten, Prof. Dr. med.
Christoph-Eckhard Heyde
Department of Physical and Rehabilitation Medicine, BG Hospital Bergmannstrost, Halle, Germany:
Dr. med. Klaus Fischer
Reha Assist Deutschland GmbH, Berlin, Germany: Dr. med. Jörg Schmidt
Collm Klinik Oschatz GmbH, Oschatz, Germany: PD Dr. med. Jörg Schnoor
Department of Orthopedic, Trauma and Reconstructive Surgery, University Hospital of Halle, Halle,
Germany: Prof. Dr. med. Stefan Delank
Department of General Orthopedic and Spine Surgery, St. Josef-Hospital Bochum, University
Hospital of the Ruhr University of Bochum, Bochum, Germany: Prof. Dr. med. Tobias Schulte
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 697–704
E
very year, an estimated 8000 severe fractures of the
thoracic and the lumbar spine occur in Germany
(1). In more than two-thirds of these cases, the
thoracolumbar junction, i.e. the thoracic vertebral bodies
T11/T12 or the lumbar vertebral bodies L1/L2 are
affected (2). For the classification of the various types of
fracture, the AOSpine classification of the AO Foun-
dation (Arbeitsgemeinschaft Osteosynthese) has become
the established standard (3). It differentiates between
compression fractures (Type A), flexion-distraction frac-
tures (Type B), and the highly unstable displaced frac-
tures (Type C) (Table 1). Complete paraplegia was
observed in 2% and incomplete neurological deficits in
11% of patients with type-A fractures (2).
The indications for conservative and surgical
management remain the subject of international con-
troversy (4, 5). Box 1 provides a summary of the treat-
ment recommendations of the Spine Working Group
of the German Society for Orthopedics and Trauma
(DGOU, Deutsche Gesellschaft für Orthopädie und
Unfallchirurgie) (4). Overall, a conservative treat-
ment strategy can be applied in many cases with
promising long-term outcomes (6, 7). However, the
type of conservative treatment is usually poorly
defined. This applies to both the intensity and type of
the therapeutic measures and the timing of the clinical
and radiographic follow-ups (5, 8).
The aim of this review, which was initiated by the
committee for conservative spine treatment of the
German Spine Society (DWG, Deutsche Wirbelsäu-
lengesellschaft), is to systematically screen the litera-
ture for content related to conservative management.
From this, the current state of evidence shall be
described for a standardized conservative treatment of
traumatic vertebral fractures of the thoracic and lum-
bar spine. Based on these results, prospective studies
could be created to increase the evidence in this field
and to produce data that can be used to further scien-
tifically support the therapeutic strategy.
Materials and methods
The literature search included recent vertebral fractures
(<4 weeks) of the thoracic and lumbar spine of adults
with adequate trauma history and without neurological
deficits. Children and adolescents (age <18 years) and
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TABLE 1

AOSpine thoracolumbar vertebral fracture classification system

Type Subtype Nomenclature Definition Frequency (%)

A A0 Process fracture/edema ● No motion segment affected 57.8 n/a*2
● No posterior vertebral wall involvement
A1 Endplate fracture ● One motion segment affected 7.5*3
● No posterior vertebral wall involvement
A2 Split fracture ● Two motion segment affected 2.7
● No posterior vertebral wall involvement
A3 Incomplete burst fracture ● One motion segment affected 20.8*4
● With posterior vertebral wall involvement
A4 Burst split/ ● Two motion segment affected 33.8*4
complete burst fracture ● With posterior vertebral wall involvement
B B1 Chance fracture ● Monosegmental osseous distraction 24.3 18.5*5
B2 Flexion injury ● Injury to the posterior ligamentous complex
B3 Extension injury ● Disruption of anterior tension band 0.9
*1
C C Displacement/translation injury ● Severe displacement 17.9 14.7*1

The definition of the AOSpine classification system according to Vaccaro et al. is stated (3) which builds on the Magerl classification system (e20). The respective
fracture frequency is stated. This is based on the Magerl classification (2).
*1
The definition of type C fractures varies between the Magerl classification and the AOSpine classification.
*2
Process fractures and fracture edema are not mentioned in the Magerl classification. Thus, the proportion of theses fractures is not reported in the literature.
*3
Since Reinhold et al. (2) included only inpatients, it can be expected that A1 fractures are underrepresented.
*4
The relative frequency of incomplete burst fractures is based on a study by Merkel et al. (e21).
*5
B1 and B2 fractures are differently defined in the Magerl classification and the AOSpine classification; therefore, the B1 and B2 fractures were combined. The
frequencies of types and the frequencies of subtypes are not fully identical due to a lack of subtype classification in 9% of patients (2).
n/a, not available

the elderly (age >65 years) with likely concomitant
osteopenia/osteoporosis are not within the scope of this
review and need to be analyzed separately. Furthermore,
patients with fractures after non-adequate trauma (trivial
falls from tripping) are not included in this review.
A systematic search of the literature was performed
by two of the authors (UJS, C-EH), including all
articles until 2/2/2018. In each case, the two databases
PubMed and Web of Science Core Collection were
considered and searched. Since data collection had
already been completed at the time of PROSPERO
registration, this review could not be registered with
PROSPERO. Using the PICO scheme (9), the follow-
ing review questions were defined:
● Do patients with non-osteoporotic traumatic
thoracolumbar vertebral fractures achieve better
clinical outcomes after operative treatment or con-
servative treatment?
● Is it possible to recommend some treatments more
than others?
The following search terms were used: (“vertebral
body fracture” OR “vertebral fracture” OR “spine
fracture” OR “lumbar spine fracture” OR “thoracic
spine fracture”) AND (“nonoperative treatment” OR
“conservative treatment” OR “orthosis” OR “brace”
OR “physiotherapy” OR “analgesia” OR “radiogra-
phy”) AND (“English” OR “German”) NOT “case
reports” NOT “reviews” NOT “osteoporosis” NOT
“osteoporotic” NOT “cervical” NOT “sacral” NOT
“odontoid”.
Subsequently, all relevant original articles were
analyzed based on their levels of evidence and their
appropriate conclusions. Here, the following topic
areas were defined:
● Diagnostic assessment of vertebral fractures
(primary diagnosis and follow-ups)
● Aids/orthoses
● Pharmacological treatment
● Non-pharmacological treatments
● Alternative medicine treatments.
Results and discussion
Altogether, 3345 abstracts were retrieved from the
literature search (Figure). Of these, 3170 articles were
excluded based on abstract or title. Most of the
excluded studies were animal experimental or bio-
mechanical studies or articles which were not original
articles or investigated other pathologies or exclusively
evaluated surgical procedures or fractures in the
elderly. Altogether, 175 articles were read completely.
Of these, further 140 articles were excluded because
the conservative treatment provided was not
adequately defined or because conservative methods
were used that are no longer up to date (for example,
bed rest for several weeks). Altogether, 3310 articles
were excluded (Figure). Levels of evidence were
defined as described by Bassler and Antes (10)
(Box 2). All 35 remaining original articles,
which covered the period from 1969 to 2018, are
summarized in Table 2.

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Initial work-up BOX 1

High-velocity trauma patients should undergo a poly-
trauma spiral computed tomography (CT) scan, cover- Indications for conservative treatment and
ing the entire spine, as recommended by the clinical operative treatment
Guideline on the Treatment of Polytrauma/Severe
Injuries (11) of the Association of Scientific Medical ● Conservative treatment
Societies in Germany (AWMF, Arbeitsgemeinschaft – Type A0 fractures
der Wissenschaftlichen Medizinischen Fachgesell- – Type A1 fractures with acceptable kyphotic
schaften). Clinical examination alone cannot conclu- deformity
sively rule out fractures (12, 13). In patients who sus- – Type A2 fractures without relevant disc injury or
tained injuries during lower-velocity type accidents, fracture displacement
conventional 2-view radiographs are indicated, subject – Lack of informed consent for surgery
to the clinical findings. If not too painful, these radio- ● Surgery
graphs should be obtained in a standing position so that – Neurological deficit
the true extent of the kyphotic deformity can be – Type C and Type B fractures
assessed. Mehta et al. (14) demonstrated a relevant – Kyphotic deformity of >15–20° (compared to
increase in bisegmental kyphosis angles (sagittal Cobb normal position
angle) on standing radiographs compared to supine – Scoliotic deformity >10°
radiographs. The bisegmental kyphosis angle was on – Immobilization in case of treatment-resistant pain
standing radiographs on average 7° larger compared to – Relevant traumatic disc damage
supine films. When evaluating local kyphosis, prefer-
ence should be given to the bisegmental kyphosis angle
determined on conventional radiographs, as it offers the
best interobserver agreement and predictive value
(15–18). Local post-traumatic kyphosis of more than bral disc (33, 34). Complementing standard MRI
20° is frequently associated with posterior ligamentous sequences, susceptibility-weighted MRI allowed im-
complex injury (19). In case a vertebral fracture was proved fracture detection not only of recent fractures,
detected or could not be reliably ruled out, an addi- but also and especially of non-healed fractures (33).
tional computed tomography (CT) scan of the suspi- Thus, accurate evaluation of injury severity can
cious segment should be obtained (20–22). In fractures only be done after complete diagnostic work-up. This
of the spine, the diagnostic performance of low-dose might include additional MRI to identify relevant in-
CT was found to be comparable to that of standard- tervertebral disc injuries and to distinguish between
dose CT, with a considerable reduction in radiation type A and type B injuries.
dose (23). The available evidence is insufficient to draw con-
Magnetic resonance imaging (MRI) is recom- clusions about the need for and significance of special
mended to accurately assess injury severity in burst radiographs, such as hypomochlion radiographs (lat-
fractures, in particular to correctly assess the posterior eral radiograph in supine position with a roll, serving
ligamentous complex (PLC) and intervertebral disc as a hypomochlion, below the vertebral body to be
lesions (24–31). Pizones et al. (24) reported that an assessed in order to determine the flexibility and sta-
injury to the posterior ligamentous complex can be bility in the affected segment of the spine), flexion
detected with a sensitivity of 91% and a specificity of and extension views, and whole-spine radiographs;
100%. Besides providing insight into the status of the
posterior ligamentous complex and ruling out poten-
tial intervertebral disc damage, MRI allows to assess FIGURE
the extent of intervertebral disc injury (31). By
contrast, Vaccaro et al. (29) found a lower sensitivity
Medline +
(range, depending on anatomical structure: 79–91%) Web of Science Core
and specificity (range: 38–67%), but nevertheless rec- (n = 3345)
ommended MRI to complement the clinical findings 3170 abstracts
as well as findings of other radiographic investi- were eliminated
gations to rule out or confirm a lesion of the posterior Requested full-text articles
portion of the spine. Furthermore, the following risk fulfilling the inclusion criteria
factors for secondary sintering after conservative (n = 175)
treatment were identified based on MRI findings: Excluded full-text
● Lesion of the anterior longitudinal ligament articles (n = 140)
● Cranial endplate lesions with involvement of the Included publications
(n = 35)
intervertebral disc (Table 1)
● Marked vertebral body edema (32).
Furthermore, secondary loss of regional sagittal
alignment was largely attributable to the interverte- Flow chart of the systematic literature review

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BOX 2
Hierarchical levels of external evidence
Ia: Evidence from meta-analyses of randomized
controlled trials
Ib: Evidence from at least one randomized controlled
trial
IIa: Evidence from at least one well-designed controlled
study without randomization
IIb: Evidence from one well-designed quasi-experimental
study
III: Evidence from well-designed, non-experimental
descriptive studies (for example comparative studies,
correlation studies, case–control studies)
IV: Evidence from reports/opinions of experts,
consensus conferences and/or clinical experiences of
recognized authorities
consequently, these special investigations are only
performed in individual cases. For example, hypo-
mochlion radiographs can be indicated during the first
four weeks in patients with regional sagittal kyphosis
of more than 10° to 15° to determine the potential for
correction.
By contrast, functional radiographs play a role es-
pecially in the evaluation of the stability of fractures
of the upper and middle cervical spine. Whole-spine
radiographs are indicated particularly in patients with
serial vertebral fractures or pre-existing deformities
and degenerative changes (35).
Diagnostic follow-ups
Regional conventional standing 2-view radiographs
should be obtained for radiographic follow-up. With
regard to the timing of follow-up examinations, the
available evidence is scarce. However, Shen et al. (36)
demonstrated a high rate of treatment failure (19%) in
type A fractures without neurological deficits. They
identified increased posttraumatic interpedicular dis-
tances between two vertebral bodies on anterior–pos-
terior radiographs and severe initial pain as risk factors
for failure of treatment and recommended clinical and
radiographic follow-ups at close intervals for patients
undergoing conservative treatment. Overall, secondary
sintering can be expected to occur over a period of at
least 3 months (37, 38). Interestingly, sponenous reduc-
tion of fracture-related spinal stenosis of almost 10%
was seen in patients who underwent conservative treat-
ment (39).
The available evidence does not allow to draw a
conclusive recommendation regarding the best timing
of radiographic follow-ups. In our view, follow-up
radiographs should be obtained after primary mobili-
zation (3–4 days), after 1, 3, 6 and 12 weeks as well as
700
with any increase in symptoms, in keeping with the
recommendation for conservatively treated extremity
fractures. The radiographic work-up is summarized in
Box 3.
Management
Aids and orthoses
Three randomized controlled trials evaluated the need
for adjunctive orthotic treatment; thus, for this question
the highest level of evidence is available among the in-
vestigated questions related to conservative fracture
management (40, e1, e2). Bailey et al. (40) used the fol-
lowing inclusion criteria: recent burst fractures of the
type A3/A4 of thoracic vertebra 10 (T10) to lumbar
vertebra 2 (L2), bisegmental kyphosis lower than 35°
and age between 18 and 60 years. The patients were
randomly assigned to the treatment groups, 47 without
orthosis and 49 with orthosis. The corset orthosis was
worn for 10 weeks. The primary outcome parameter
was the Roland Morris Disability Questionnaire
(RMDQ) assessed at 3 months after the injury (e3).
Secondary outcome parameters included the SF-36
score, VAS (visual analog scale) pain score, patient
satisfaction, and bisegmental kyphosis at weeks 6 and
12 as well as months 6, 12 and 24. The follow-up rates
were 95% after 3 months, 85% after 1 year and 70%
after 2 years. No statistically significant differences
were found between the two treatment groups, neither
for the primary nor for the secondary outcome
parameters, at any point in time during the follow-up
period.
Stadhouder et al. (e1) included patients with recent
compression fractures (A1–A4) with <50% loss of
height of the anterior column and <30% stenosis of
the spinal canal of the entire thoracic and lumbar
spine, and conservative treatment. The age limits were
18 and 80 years. The primary outcome parameter was
the bisegmental kyphosis angle. The secondary out-
come parameters were the VAS pain score and the
Oswestry Disability Index (ODI) (e4). Follow-up
visits were scheduled at 6 and 12 weeks, 6 and 12
months, and at least 2 years after the injury. Alto-
gether, 133 patients were included. Of these, 29 were
treated with physiotherapy alone, 38 plus a corset
orthosis, 27 and 39 patients plus a plaster of Paris cast
for 6 and 12 weeks, respectively. The follow-up rate at
the time of the last follow-up visit, which occurred
after 7 years on average, was 75%. Overall, no differ-
ences were found for the primary outcome parameter,
the sagittal alignment, between any of the treatment
groups. Management without corset orthosis was per-
ceived as the most convenient treatment. Patient
treated with a plaster of Paris cast experienced clinical
disadvantages compared to the other treatment groups.
In addition, a minor, but statistically significant
reduction in spine-associated limitations was found
for the orthosis group compared to the group without
orthosis. A critical point, however, is the inclusion age
of 80 years, as it implies that most likely patients with
osteoporotic fractures were included in the study. This
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TABLE 2
List of all included studies and their key messages
Article with study design [level of evidence]
Inaba et al. 2011 (12)
Venkatesan et al. 2012 (13)
Mehta et al. 2004 (14)
Kuklo et al. 2001 (15)
Street et al. 2009 (16)
Jiang et al. 2012 (17)
Ulmar et al. 2010 (18)
Hiyama et al. 2015 (19)
Campbell et al. 1995 (20)
Dai et al. 2008 (21)
Ballock et al. 1992 (22)
Lee et al. 2017 (23)
Pizones et al. 2011 (24)
Lee et al. 2000 (25)
Petersilge et al. 1995 (26)
Haba et al. 2003 (27)
Terk et al. 1997 (28)
Vaccaro et al. 2009 (29)
Winklhofer et al. 2013 (30)
Oner et al. 1999 (31)
Jun et al. 2015 (32)
Böker et al. 2018 (33)
Shen et al. 2015 (36)
Alanay et al. 2004 (37)
Loew et al. 1992 (38)
Dai 2001 (39)
Bailey et al. 2014 (40)
Stadhoulder et al. 2009 (e1)
Shamji et al. 2014 (e2)
Karjalainen et al. 1991 (e6)
Ohana et al. 2000 (e7)
Cha et al. 2013 (e10)
Kürschner et al. 1980 (e11)
Melzer et al. 1974 (e12)
Andersen und Horlyck 1969
(e13)
Cohort, cohort study; comparison, comparison study; case–control, case–control study;
RCT, randomized controlled trial, CT, computed tomography; MRI, magnetic resonance imaging; VAS, visual analog scale
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Question Key messages
Cohort [III] Is clinical examination alone ● In patients with high-velocity trauma, clinical examination
Case series [IV] sufficient to exclude or confirm alone is not sufficient to exclude or confirm suspected
suspected vertebral fracture? vertebral fracture.
Cohort [IIa] Radiographic positioning ● Bisegmental kyphosis angle (sagittal Cobb angle)
significantly higher in standing position
Comparison [III] Determining regional ● Best reliability by measuring bisegmental kyphosis angle with
Comparison [III] malpositioning best inter- and intraobserver reliability
Comparison [III] ● Highest reliability with conventional radiography
Comparison [III]
Case series [IV] Radiographic evaluation of the ● Signs of injury to the posterior column include:
posterior ligament complex ○ local kyphosis >20°
○ increased supraspinous distance
Cohort [III] Is conventional radiography ● Good fracture verification, but limited fracture classification
Comparison [III] sufficient for assessment of ● In comparison with CT, the negative predictive value for
Comparison [III] stability? unstable fractures was 62%
● Consequently, a CT scan is required
Case–control [III] Comparison between low-dose ● Comparable diagnostic accuracy with reduction of radiation
CT and standard-dose CT dose by 47–69%
Cohort [III] Significance of MRI for posterior ● Accurate evaluation of the posterior column with differences
Comparison [III] ligament complex evaluation in sensitivity (85–91%) and specificity (56–100%)
Cohort [IV] ● Detection of posterior column lesions not detected with
Comparison [III] conventional radiography and CT in 19% of cases
Cohort [III]
Comparison [III]
Comparison [IV] Significance of MRI for primary ● MRI allows assessment of extent of intervertebral disc
Case series [IV] fracture diagnosis damage and assessment of disc protrusion into the fracture
gap.
● Following MRI, fracture reclassification was required in 31%
of patients (upgrading in 28%).
Case series [IV] MRI risk factors for secondary ● Injury to the anterior longitudinal ligament
sintering after conservative ● Cranial endplate injury with involvement of the disc
treatment ● Marked edema of the vertebral body
Comparison [III] Diagnostic accuracy of ● More accurate in the evaluation of vertebral fractures,
susceptibility-weighted MRI especially non-healing fractures
Cohort [III] Risk factors for failure of ● Risk factors for type A fractures:
conservative treatment ○ Increased interpedicular distance between two vertebral
bodies
○ High initial VAS pain scores
Cohort [III] Period during which secondary ● Secondary sintering was observed for up to 3 months.
Cohort [III] sintering can be expected
Case series [IV] Development of posttraumatic ● Extent of spinal stenosis is diminished after conservative
spinal stenosis treatment by 8.5%.
RCT [Ib] Comparison of management ● Significantly shorter inpatient stay without corset orthosis
RCT [Ib] with or without orthosis ● No clinical or radiographic difference after treatment with or
RCT [IIa] without orthosis
Case–control [III]
Case–control [III]
Case–control [III] Advantages and disadvantages ● Lower complication rate with early mobilization
Case series of early mobilization ● Better outcomes after early mobilization
Case series [IV] ● Early mobilization shortens length of inpatient stay
Case series [IV] ● No negative effect on alignment
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BOX 3
Diagnostic procedure for traumatic vertebral fractures of
the thoracic and lumbar spine in patients with normal
bone density
● CT scan in case of high-velocity trauma in keeping with clinical (S3) guideline
Polytrauma
● Otherwise, primarily conventional 2-view radiography
● Conventional radiography, if possible, in standing position
● If fracture is suspected, a computed tomography (CT) scan should be
performed for more accurate evaluation of fracture morphology
● Follow-up radiographs should be obtained after mobilization (3–4 days) and at
weeks 1, 3, 6, and 12.
● In case of burst fractures, magnetic resonance imaging (MRI) is indicated to
rule out a B component and to evaluate the intervertebral disc damage
● Determining the bisegmental kyphosis angle on conventional radiographs
offers the highest interobserver agreement
view is supported by the finding that some patients
sustained fractures as the result of low-velocity trau-
mas. This point is very relevant because, in contrast to
patients with normal bone density, it is assumed that
patients undergoing conservative treatment for osteo-
porotic vertebral fractures benefit from corset treat-
ment due to a muscle-stimulating effect potentially
associated with wearing the orthosis (e5).
Shamji et. al. (e2) reported about patients with
recent A3 or A4 fractures of T10 to L4. The primary
outcome parameter was the bisegmental kyphosis
angle at 6 months follow-up. Secondary outcome pa-
rameters were the VAS pain score, ODI score and
SF-36 score at 6 months follow-up. Altogether, 23
patients were included. All 23 patients were re-evalu-
ated at 6 months follow-up. Looking at all outcome
parameters, no statistically significant or clinically
relevant differences were found between patients with
and without orthosis.
This is in line with the findings of two level III
studies which found no clinical or radiographic
advantages of orthotic treatment (e6, e7).
In summary, based on the available evidence,
orthotic treatment is not indicated as part of the
conservative management of fractures of the thoracic
and lumbar spine in patients with normal bone
density. However, in individual cases, treatment
with a corset orthosis can be a beneficial component
of conservative fracture management due to its
analgesic effect. Further randomized multicenter
studies with selective inclusion of traumatic fractures
and comparable types of fracture are needed to
re-evaluate the usefulness of orthotic treatment.
Here, sub-analyses of matched-pair data taking into
account fracture type and fracture location would be
advantageous.
702
BOX 4
WHO’s three-step Pain Relief Ladder *
● Step 1
– Non-opioid analgesics
● Step 2
– Weak opioid analgesics
● Step 3
– Strong opioid analgesics
* Optionally, muscle relaxants can be added at each of the 3 steps
Physiotherapy and manual therapy
The need for adjunctive physiotherapy is generally
emphasized, but studies comparing specific types of
treatment have not been performed. Even widely recog-
nized aftercare recommendations provide no explicit
information about the frequency of treatment and
specific types of treatment (e8, e9).
In summary, no evidence-based studies evaluating
the indication for and efficacy of adjunctive treat-
ments in patients with vertebral fractures of the tho-
racic or lumbar spine are available. Nevertheless,
there are some interesting aspects which could be
adopted, although with reservation. For example, Cha
et al. (e10) found in their prospective randomized
study that in patients with osteoporotic vertebral
fractures the complication rate is significantly lower
if adjunctive physiotherapy is started early—with
comparable degrees of pain and similar secondary
sintering. From this finding for osteoporotic fractures
it can be concluded that a similar positive effect of
starting adjunctive physiotherapy at an early point can
be expected for non-osteoporotic fractures as well. In
addition, early functional treatment significantly
reduced the length of inpatient stay without negative
effects on alignment (e11–e13). Here, isometric train-
ing appears to result in an increase in muscle size
comparable to that achieved with flexion exercises,
while offering the advantage of less forces acting on
the fracture (e14).
With little evidence available, there is no indication
for manual therapy in the management of recent frac-
tures.
Likewise, there is a lack of evidence regarding the
usefulness of physical therapy, such as hot and cold
applications, ultrasound, electrotherapy, and alter-
native types of treatment, such as magnetic field
therapy and acupuncture.
Pharmacotherapy
Very little evidence is available with regard to the
management of pain in patients with non-osteoporotic
vertebral fractures. Our systematic search of the litera-
ture identified no article dealing with the aspect of
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analgesic treatment which could be included in this
review. Consequently, it is not possible to make any
systematic review–based recommendations for a specific
analgesic treatment as a component of the conservative
management of traumatic vertebral fractures of the
thoracic and lumbar spine.
Therefore, we recommend—taking patient age,
concomitant diseases and contraindications into ac-
count—to follow the pharmacological pain manage-
ment for osteoporotic vertebral fractures (e15) and the
World Health Organization’s (WHO) three-step Pain
Relief Ladder (Box 4) (e16) when providing pharma-
cological pain relief to this patient population.
Non-opioid analgesics (NOPA)
This group includes nonsteroidal anti-inflammatory
drugs (NSAIDs), coxibs and metamizole (Step 1, WHO
Pain Relief Ladder). Because of their anti-inflamma-
tory potential, initially drugs of the NSAID group are
selected. In case of intolerance or contraindications, the
off-label use of coxibs may be considered. Data on the use
of metamizole is still scarce, even though the substance
has been administered over decades, especially in Ger-
many, and proven its effectiveness for pain relief (e17).
Opioids
In patients with severe pain or inadequate response to
NOPAs, weak opioid analgesics (tramadol, tilidine/nal-
oxone; Step 2, WHO Pain Relief Ladder) can be used in
addition (e15). In order to reduce the risk of addiction,
the use of sustained-release formulations, administered
according to a fixed schedule, is advisable (e18).
In patients with persisting or increasing severe
pain, the use of strong opioids may be considered
(Step 3, WHO Pain Relief Ladder). All opioids share
a sedating effect, which, in combination with dizzi-
ness, may increase the risk of falling.
Muscle relaxants
Muscle relaxants, in combination with other analgesics,
can be used as an adjuvant in pain management to
facilitate opioid weaning. Due to their side-effect pro-
file, muscle relaxants should not be used for longer
than 2 weeks (e19).
Conclusion
The available evidence on the conservative treatment of
traumatic vertebral fractures of the thoracic and lumbar
spine is scant. In the future, further studies in all areas
of conservative fracture treatment are urgently needed
and considered highly desirable. This includes prospec-
tive comparative studies on
● Physiotherapeutic strategies, such as density and
contents of treatments
● Duration and extent of restrictions (lifting heavy
loads)
● Types of analgesia and their advantages and dis-
advantages
● Timing and frequency of follow-up radiographs
with regard to potential therapeutic consequences.
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 697–704
MEDICINE
Key messages
● Use conventional radiography for primary assessment
● If fracture is suspected, a computed tomography (CT) scan is indicated.
● In case of burst fractures (incomplete and complete), magnetic resonance imaging
(MRI) is recommended.
● Conservative management should consist of early functional treatment without
corset orthosis.
● In individual cases, orthotic treatment can be indicated because of its analgesic
effect.
● Follow-up standing radiographs should be obtained after mobilization and at weeks
1, 3, 6, and 12 of follow-up.
Conflict of interest statement
Prof. Heyde received consulting fees from Medacta International. Further-
more, he received funding in a third-party funding account from Medacta
International.
Prof. Delank, Dr. Fischer, Dr. Schmidt, Prof. Josten, Dr. Schnoor,
Prof. Schulte, and Dr. Spiegl declare that no conflict of interest exists.
Manuscript received on 15 May 2018; revised version accepted on
5 September 2018
Translated from the original German by Ralf Thoene, MD.
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Corresponding author
PD Dr. med. Ulrich J. Spiegl
Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie
Universitätsklinik Leipzig
Liebigstraße 20, 04103 Leipzig, Germany
Uli.spiegl@gmx.de
►Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref4218
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 697–704

Supplementary material to:
The Conservative Treatment of Traumatic Thoracolumbar
Vertebral Fractures
A Systematic Review
by Ulrich J. Spiegl, Klaus Fischer, Jörg Schmidt, Jörg Schnoor, Stefan Delank,
Christoph Josten, Tobias Schulte, and Christoph-Eckhardt Heyde
Dtsch Arztebl Int 2018; 115: 697–704. DOI: 10.3238/arztebl.2018.0697
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